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   Table of Contents - Current issue
Coverpage
July-December 2018
Volume 5 | Issue 2
Page Nos. 59-129

Online since Thursday, July 26, 2018

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EDITORIALS  

The road ahead p. 59
Srinivas Gosla Reddy
DOI:10.4103/jclpca.jclpca_20_18  
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Cleft care in India: Current scenario and future directions p. 60
Divya Narain Upadhyaya
DOI:10.4103/jclpca.jclpca_19_18  
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STATE OF THE ART Top

Unilateral cleft lip: A review and current status p. 62
Anthony F Markus
DOI:10.4103/jclpca.jclpca_16_18  
Primary surgery for cleft lip remains a challenge for all surgeons. This review seeks to identify the important underlying theories that have led to current practice, that will produce the best outcomes and to encourage collaboration in surgical practice, assessment and research in this area.
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Intravelar veloplasty: A review p. 68
Rajshree Jayarajan, Anantharajan Natarajan, Ravindranathan Nagamuttu
DOI:10.4103/jclpca.jclpca_18_18  
Good speech is the ultimate aim in palate repair. Muscle function has to be optimum for the palate to be able to move to provide this goal. The fact that there has been a multitude of techniques of palatal repair indicates that none has been able to attain the intended objective. The method of intravelar veloplasty as a funtional technique has been the one that has gained wide acceptance all over the world. Use of magnification loops and microscope and better understanding of the cleft anatomy has helped to further refine the technique. This review aims at evaluating the outcome of this technique and its various modifications and complications. Literature search was performed in PubMed, Embase and Lilacs Bireme using the terms 'intravelar veloplasty', 'cleft palate repair', and radical muscle dissection'. No restriction were placed with regards to date of publication or language. Abstracts of the articles were assessed and the selected articles were reviewed in full by the authors. There is a striking diversity in the extent of muscle dissection between cleft surgeons. The evidence from the studies available showed better speech outcomes and velopharyngeal competence with radical intravelar veloplasty with varying complication rates. Uniformity in defining the degree of dissection of muscle by using a classification and standardised methods of outcome measurements are to be used in future studies to provide high quality evidence to guide decisions.
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REVIEW ARTICLE Top

Clinical utility of cone-beam computed tomography in patients with cleft lip palate: Current perspectives and guidelines p. 74
Shahista Parveen, Akhter Husain, Rohan Mascarenhas, Srinivas Gosla Reddy
DOI:10.4103/jclpca.jclpca_7_18  
The aim of this article is to provide a comprehensive review of the application of cone-beam computed tomography (CBCT) in individuals with cleft lip and palate (CLP). A literature search was conducted from September 2016 to December 2017 in Medline, Scopus, ScienceDirect, Google Scholar, and Ebscohost databases using keywords “CBCT, cleft lip and palate.” The inclusion criterion was any published original article where CBCT was used to assess the craniofacial structures in patients with CLP. An additional Google and manual search was carried out by examining the references of the included articles. All retrieved relevant articles (69 original articles) were tabulated under different sections and analyzed. Data were tabulated as follows – CBCT in the assessment of craniofacial structures in CLP, first author, year of publication, study design, characteristics of the study population and number of participants, age/gender distribution, and conclusions of the studies which are also described in the narrated review. Apart from this, the search also included guidelines for the application of CBCT in patients with CLP. This article gives the cleft team a compilation of all recent literature regarding the use of CBCT in patients with CLP, which helps in providing better care for patients with CLP, keeping in mind the various guidelines issued by different professional bodies regulating the welfare of patients.
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ORIGINAL ARTICLES Top

Cephalometric evaluation of patients treated by maxillary anterior segmental distraction p. 88
Shanahaz Kuzhippayi Saidalavi, Balakrishna Shetty, Goutham Reddy, Sunil Muddaiah, Sanju Somaiah, Roopa Sidde Gowda
DOI:10.4103/jclpca.jclpca_5_18  
Background: Maxillary hypoplasia secondary to repaired cleft lips and palates is common. The extent of hypoplasia is dependent on several factors. It is not possible to correct maxillary hypoplasia by conventional orthodontics and relapse is common after orthognathic advancement of the maxilla with or without grafts. Distraction osteogenesis (DO) offers a promising alternative for the management of congenital and acquired facial deformities that require bone lengthening. It is less invasive than traditional surgical techniques, requires less surgical time, and eliminates the need for a donor site operation. In addition, simultaneous soft-tissue expansion may improve long-term skeletal stability. DO allows the body's natural healing mechanisms to generate new bone for augmenting or lengthening bone. The purpose of this study was to enumerate and compare dental, skeletal, and soft-tissue changes, and postoperative stability using cephalometric analysis following anterior maxillary DO in cleft patients. Aims and Objectives: (i) The aims and objectives of this study were to enumerate and compare dental, skeletal, and soft-tissue changes, and postoperative stability using cephalometric analysis following premaxillary DO and (ii) to draw clinical inference from the above results. Methods: Seven female patients underwent anterior maxillary DO with a mean age of 19 years, and the anterior movement of premaxillary segment was generated by tooth-borne distractor with a rapid maxillary expansion screw. The distraction of the premaxilla was stopped after achieving a positive profile and sufficient space to align the maxillary dentition. After the consolidation period, the distractor was removed and orthodontic treatment was started with fixed appliances to level the teeth. Cephalometric data of patients were collected before treatment (T1), after distraction (T2), and 6 months after distraction. Comparison between time periods T1–T2, T1–T3, and T2–T3 were done to evaluate the dental, skeletal, and soft-tissue changes brought by DO. Results: In all the patients, the treatment objective was achieved with a positive overjet and improved profile without changing the position and intermaxillary relation of the posterior. There was a significant horizontal increase of the premaxilla with a definite gain in the maxillary dental arch length for alignment of the maxillary dentition with a downward and backward movement of the mandible. Conclusion: Maxillary DO offers an effective technique to transpose the maxilla forward and downward in moderate-to-severe maxillary retrusion. DO offers better stability due to the gradual expansion and lengthening of the soft tissue in response to the gradual traction. It avoids the complication of acute reconstructive surgical methods and minimal trauma when compared to other alternative surgical methods. It also shortens the overall treatment time due to reduced need for comprehensive treatment time.
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Evaluation of velopharyngeal changes and mechanisms in upper airway following maxillary advancement by LeFort I osteotomy in patients with cleft: A retrospective study p. 97
Swati Saraswata Acharya, Satyabrata Patnaik, Sobhan Mishra, Subrat K Padhiary, Nitu Gautam, Pritam Mohanty
DOI:10.4103/jclpca.jclpca_9_18  
Introduction: Velopharyngeal dysfunction after maxillary advancement in Lefort I osteotomy may be a result of velopharyngeal insufficiency in patients with cleft. Maxillary hypoplasia is often related to a combination of congenital decrease in midfacial growth and surgical scar from cleft palate repair. Aims and Objectives: The aims and objectives of this study are to evaluate and correlate the velopharyngeal changes during and after maxillary advancement in patients with cleft after Lefort I osteotomy. Materials and Methods: Thirty Class III patients were included in this study. Maxillary advancement was done with Lefort I osteotomy. Cephalometric, nasopharyngoscope, and nasometer records were taken before, immediate postoperative and 1 year after advancement. A paired t-test was used to find the differences at P < 0.05. Results: The range of maxillary advancement was almost at mean of 9 mm. Statistical increase in the anteroposterior distance of superior, middle and inferior velopharynx, nasopharyngeal and oropharyngeal dimensions, angle of velar, and need ratio was found (P = 0.0001). There was a significant increase in nasalance scores (P < 0.041). Sagittal maxillary changes were 9.77° postadvancement. Vertical changes in maxilla, ANS, and peripheral nerve stimulation relative to X-axis (P = 0.0001, 0.0001 and 0.018) significantly increased after surgery. A significant positive correlation was seen between the amount of maxillary advancement and increase in depth of nasopharynx (P = 0.0001). Conclusions: The maxilla was advanced forward causing increased nasopharyngeal depth. There was a positive correlation between the amount of maxillary advancement and nasopharyngeal depth.
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Three-dimensional assessment of alveolar bone thickness in individuals with nonsyndromic unilateral complete cleft lip and palate p. 106
Shahista Parveen, Roopali Shetty, Akhter Husain, Rohan Mascarenhas, Neevan D'Souza, Nandish Kumar Shetty
DOI:10.4103/jclpca.jclpca_11_18  
Background: Patients with cleft lip and palate (CLP) present with thin alveolar bone around the defect. Thin alveolar bone compromises orthodontic treatment. The aim of this study was to carry out three-dimensional (3D) assessment of the thickness of alveolar bone around the teeth adjacent to cleft and to compare the thickness of alveolar bone between cleft and noncleft side. Materials and Methods: Retrospective database of 16 cone-beam computed tomography (CBCT) scans of individuals with nonsyndromic unilateral complete CLP reported to two cleft centers in the year 2015 and 2016. Alveolar bone thickness of the teeth anterior and posterior to the cleft side in the buccal, lingual, mesial, and distal at three levels (3 mm, 6 mm, and 1 mm below the apex) from the cementoenamel junction (CEJ) using Dolphin 3D imaging software were measured. CBCT images of each cleft patient are divided into two groups, cleft and noncleft site. Each cleft side is subdivided into 1. Tooth anterior to the cleft 2. Tooth posterior to the cleft. Alveolar bone thickness of teeth at labial/buccal, palatal, and mesial/distal surfaces was measured. These subdivided groups were compared to contralateral teeth on the noncleft sites for individual surface. Statistical Analysis Used: Wilcoxon signed-ranks test and descriptive statistics were used. Results: The average alveolar bone thickness on the labial surface for teeth anterior to the cleft at 3 mm from CEJ is 0.15 (0, 0.80) mm and noncleft site is 0.85 (0.58, 1.28) mm (P < 0.05). The average alveolar bone thickness on the distal surface for teeth anterior to the cleft at 3 mm from CEJ is 0.90 (0.00, 1.65) mm and noncleft site is 1.11 (1.23, 3.60) mm (P < 0.05). The average alveolar bone thickness on the mesial surface for teeth posterior to the cleft at 3 mm from CEJ is 1.10 (0108, 1.38) mm and noncleft site is 1.45 (1.23, 1.98) mm (P < 0.05). Conclusions: The alveolar bone around the cleft sites is thin when compared with noncleft sites.
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A retrospective study of tibial cancellous bone grafting in the management of alveolar clefts p. 113
Abbas Asgharali Mistry, Yusuf Abbas Mistry, Chintamani Kale, Taher Abbas Mistry, Dhimant Kuldeep Singh Goleria, Balaji Anantrao Samudre
DOI:10.4103/jclpca.jclpca_13_18  
Introduction: This is a retrospective study to assess the outcomes of tibial bone grafts in secondary grafting of alveolar clefts. Tibial cancellous bone harvested from upper-end diaphysis is believed to be qualitatively similar to iliac bone without the known morbidities of the donor site. Patients and Methods: The study comprises of 54 patients with complete alveolar clefts treated at our institute. The quality of graft take was graded radiologically using Bergland's criteria. The patients were followed up for complications, longest follow-up being 10 years. Results: The success rate was 96.3% for the sample. There were two cases, one of complete and one of partial bone loss each with recurrence of fistulae. A single case of wound infection at donor site was seen. On long-term evaluation, we had one case of slight hypertrophic scarring. Conclusion: Tibial cancellous bone graft provides good quality of viable bone for alveolar bone grafting without the accompanying morbidity. Hence, it is an excellent alternative to iliac crest bone grafting.
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CASE SERIES Top

Figueroa modified presurgical nasoalveolar molding for cleft patients: A case series of three cases p. 119
Divya Doneria, Seema Thakur, Anika Uppal, Alka Chauhan
DOI:10.4103/jclpca.jclpca_1_18  
Presurgical nasoalveolar molding (PNAM) is a modified approach of presurgical infant orthopedics for cleft lip and palate (CLP) patients. PNAM provides the advantage of reduction in the nasal deformity along with reduction in the severity of the alveolar defect before surgery. Nonsurgical nasal correction, achieved by nasoalveolar molding, helps the surgeon to achieve better postoperative finer surgical scar, good nasal tip projection, and more symmetrical nasolabial complex. This clinical case report presents a series of three cases of a child with CLP, two with complete unilateral, and one with incomplete bilateral. These cases were treated with Figueroa modified PNAM technique before primary lip repair surgery.
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CASE REPORT Top

Surgical management of a vomeropremaxillary fracture in a patient with complete bilateral cleft lip and palate following trauma p. 124
Karan Sharma, Shalvi Singh, Puneet Batra, SC Sood
DOI:10.4103/jclpca.jclpca_10_18  
Timing of treatment of protruding premaxilla in a bilateral cleft lip and palate (BCLP) patient is an issue of dilemma. Fracture of the premaxillary segment following trauma in a patient with complete BCPL is presented. Salvaging the mobile premaxilla becomes an emergency. Surgical management of such a fracture has been discussed in a patient with repaired cleft lip and palate in the light of recent literature.
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LETTER TO THE EDITOR Top

Three-dimensional assessment of alveolar bone thickness in individuals with nonsyndromic unilateral cleft lip and palate p. 128
Madhumitha Natarajan
DOI:10.4103/jclpca.jclpca_14_18  
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